An Obstetric Crisis

Chris Elton, Helena MayburyUHL Leicester

Rachel Collis, Peter CollinsUCW Cardiff

OAA AGM Manchester 20th May 2016

Declarations

• OBS2 study (Multicentre Fibrinogen replacement in MOH) funded by CSL Behring with equipment support from TEM International GmbH

• The case is “a bit made up” (for confidentiality and educational reasons)

Case • 30 yr old woman, 1st pregnancy, 37/52• Medical history unremarkable• 79kg BMI 30• Admission via GP with high blood pressure and abdominal

pain

• 1730 hrs admitted to MAU• BP 150/100• No proteinuria• Tender abdomen• Registrar review transfer to delivery suite• Plan CTG, PET bloods

Case

• Transfer to delivery suite• On CTG initially decreased variability• Bloods taken including Group and Save• 1445 sudden abdo pain• Tender hard uterus• BP170/100• Frank blood loss from vagina• Fetal bradycardia• Emergency Buzzer…...

Placental Abruption

• Rare event, 0.7% of pregnancies

• Accounts for 12-15% of perinatal deaths in UK & US

• Clinical diagnosis which is only confirmed at delivery

Making the diagnosis

• 247 cases of abruption, 2003-2012• Incidence: 0.4%

• APH 81.9%• Uterine hypertonia 26.1%• Abdominal pain 27.8%

• Abnormal FHHR 64.8%

• APH and abnormal fetal heart rate 39.3%

9.7%

Boirame et al Eu J Obs&Gyne 2014

Outcomes

PA Controls P value

CS 90.3% 19.8%

Risk factors

OR 95% CI

Smoking 2.1 2.0-2.2

Cocaine and opiate use 2.3 1.4-3.9

PPROM 3.05 2.16-4.32

Pre-eclampsia 1.73 1.47-2.04

Gestational hypertension 3.13 2.04-4.8

Recurrence risk: highest in women whose 1st abruption was >37 weeks, uncomplicated pregnancy.

Anaesthesia

• Anaesthetist arrives…............• “Abruption”• Cat 1 CS; GA requested• Vaginal blood loss 500ml• 2nd cannula• Bloods for TEG/ROTEM

What is happening to the blood?

• ROTEM/TEG• Activation of clotting cascade• Consumption of clotting factors• Consumption of fibrinogen

What’s Happening to the Blood?

• Do a TEG/ROTEM?• What is likely to be happening

haematologically?• Preeclampsia• Abruption consuming clotting factors

particularly fibrinogen

Rotem-Extem/Fibtem TEG

Anaesthesia

• “How long have I got?”

Emergency Caesarean Section

• Grade 1 An immediate threat to the life of the mother or fetus -Emergency

• Grade 2 Maternal or fetal compromise that was not immediately life threatening -Urgent

• Grade 3 The mother needed early delivery but there was no maternal or fetal compromise -Scheduled

• Grade 4 Delivery was timed to suit the mother or staff-Elective

• Lucas et al Urgency of caesarean section: a new classification JRSoc Med 2000 93 346

Categories of Caesarean Section (US)

• Stat (Super STAT)• Condition that is immediately life threatening for mother or fetus

– Massive haemorhage– Ruptured Uterus– Cord prolapse with fetal bradycardia– “Agonal” fetal distress

• Urgent• Maternal or fetal physiology is unstable but not immediately life

threatening– Dystocia– Failed trial of forceps– Cord prolapse without fetal distress

• Stable• Stable physiology

– Chronic Uteroplacental insufficiency– Abnormal fetal presentation with ruptured membranes

Grade of Caesarean Section (%)Sentinel Audit 2001

Thomas, Paranjothy. RCOG CESU, National Sentinel Caesarean Section Audit RCOG press London 2001

Chart1

Grade 1

Grade2

Grade 3

Grade 4

Grade of Caesarean Section

16

32

18

31

Sheet1

Grade of Caesarean Section

Grade 116

Grade232

Grade 318

Grade 431

To resize chart data range, drag lower right corner of range.

“Grade 1 CS” -Sentinel 2001

• All births 3 months England and Wales• 152,139 births; 32,222 caesarean sections

• Median delivery time 27 minutes• 25% delivered in 18 minutes• 75% delivered in 45 minutes• STANDARD NOT ACHIEVED (30 mins)

Don’t Believe Everything You’re told!

• Sentinel (2001)• FBS performed pH greater than 7.2 (19%)

• Half the Grade 1 CS were reclassified (8% not 16%)• Emergency CS makes up about 2% of births• Thomas, Paranjothy. RCOG CESU, National Sentinel Caesarean Section

Audit RCOG press London 2001

Decision to Delivery Timing

• 30 min rule was/is “pragmatic” standard• More likely to be met if patient in theatre within

10 minutes of decision• Availability of 2nd theatre• Shortening decision to delivery does not reduce

admission to NICU or neonatal acidaemia• Tuffnell et al BMJ 2001 1330• MacKenzie et al BMJ 2001 1334• Dunphy et al J Obstet Gynecol 1991 211

Decision to Delivery Timing

• Decision to Delivery Times less than 20 mins associated with INCREASED fetal compromise

• (Hillemans et al 2005 Arch Gynecol Obstet 161-5)

• Analysis of Sentinel Study patients showed NO difference provided DDI was less than 75 minutes

• (Thomas et al BMJ 2004 665)

“Special Cases”

• Placental Abruption with Fetal Bradycardia• 20 mins vs 30 mins reduced neonatal morbidity and

mortality (OR 0.44 0.22-0.86)• Kayani et al 2003 BJOG 679-83

• Bleeding vasa/placenta praevia/fetal haemorhage

• Cord Prolapse with absent pulsation• Uterine dehiscence with fetal extrusion

Transfer to theatre

• General Anaesthesia

General Anaesthetic

• Propofol/Thiopentone

• Opioid?

• Suxemethonium/Rocuronium

• Uneventful Intubation

• ROTEM

ROTEM

Caesarean section• Uterus opened, placenta almost completely separated,

large retro-placental clot• 2 litres blood in uterus: EBL 2.5 litres• “Flat baby”• Cord gases• pH 6.9 BE -15• Uterine Atony• Maternal BP maintained at 90 with phenylephrine• 3 litres Hartmanns• 2U O –ve blood• Hb 7

TEG

Atonic Uterus

Consumption of Fibrinogen and Platelets

Bleeding Into Uterine Cavity

Uterotonics

Blood Products/Drugs

Surgery/EUA

Stopping the Source

• Contract Uterus• Give Uterotonics• “Rubbing up a contraction”• Bimanual compression• Repair• Intrauterine balloon/Uterine Packing• B-Lynch Suture • Vascular procedures• Interventional radiology• Hysterectomy

Stopping the Source

• Contract Uterus• Give Uterotonics• “Rubbing up a contraction”• Bimanual compression• Repair• Intrauterine balloon/Uterine Packing• B-Lynch Suture • Vascular procedures• Interventional radiology• Hysterectomy

Making the Uterus Contract

Drugs to Contract the Uterus

• Syntocinon• Intravenous/Intramuscular• Dose 0.3-3-5U, 0.3-10U/hour (pump)• Vasodilatation/Hypotension/Tachycardia• Fluid retention

• Carbetocin• Synthetic analogue oxytocin• Half life 4-10X longer• Similar side effects

Drugs to Contract the Uterus

• Ergometrine• Ergot alkaloid• Longer duration of action• IV/IM 0.25-0.5mg• Nausea/Vomiting• Hypertension (do not use in PET)

Drugs to Contract the Uterus

• Misoprostol• Prostaglandin E1 analogue• Rectal or Intracavity (600-800mcg-1000mcg)• NOT licensed• Nausea/Vomiting• Pyrexia/Shivering• Diarhoea

Drugs to Contract the Uterus

• Carboprost– Synthetic Prostaglandin F2alpha– Dose 0.25mg, 15 mins, Max 2mg – Intramuscular/myometrium(?)– Histamine release/Smooth muscle contraction– Hypertension– Hypoxia

» Bronchoconstriction ?asthma» Shunting» Pulmonary Oedema

Blood Products

• Blood 4U• Cryoprecipiate 2U pooled (10U)• FFP 2U• Platelets 1U pooled (5U)

Haemaostasis• Blood given Total 6U • Cryoprecipitate 2U• FFP 2U• Platelets 2U

• ABG’s pH 7.3 BE -5; Hb 9

• Extubated• Baby goes for cooling, good recovery• After extubation clotting results ready…......

• 62 cases of cord prolapse• 34 pre training • Joint midwifery, obstetric and anaesthetic training every year• Training on management up to transfer to theatre• 28 post training• Reduction in DDI from 25 to 14.5 minutes

Summary

• Point of care testing can track clotting changes rapidly and direct transfusion

• Fibrinogen falls rapidly abruption• Abruption requires a rapid response• Anaesthetic issues need to be communicated to

the whole team• Blood and blood products may be delayed• Lab results may not be helpful in an acute bleed

An Obstetric Crisis��Slide Number 2Slide Number 3Slide Number 4Slide Number 5Slide Number 6DeclarationsCase Case Slide Number 10Placental AbruptionMaking the diagnosisOutcomesRisk factorsAnaesthesiaSlide Number 16What is happening to the blood?Slide Number 18Slide Number 19Slide Number 20What’s Happening to the Blood?Rotem-Extem/Fibtem TEGAnaesthesiaSlide Number 24Emergency Caesarean SectionSlide Number 26Categories of Caesarean Section (US)Grade of Caesarean Section (%)�Sentinel Audit 2001“Grade 1 CS” -Sentinel 2001Don’t Believe Everything You’re told!Decision to Delivery TimingDecision to Delivery Timing“Special Cases”Transfer to theatreSlide Number 35Slide Number 36General AnaestheticROTEM Caesarean sectionTEGSlide Number 41Stopping the SourceStopping the SourceMaking the Uterus ContractSlide Number 45Drugs to Contract the UterusDrugs to Contract the UterusDrugs to Contract the UterusDrugs to Contract the UterusBlood ProductsSlide Number 51HaemaostasisSlide Number 53Summary